Diagnosing bias: Racial animus continues to negatively affect community health

A recent study published in the Journal of the American Heart Association suggested that black patients hospitalized for heart attacks continue to receive different medical treatment than white patients.1 This is the latest in a series of reports of well-documented racial differences in medical care despite ongoing efforts by providers to eliminate or at least reduce them. These reports have wide-ranging implications for providers as well as the communities they serve.

In this study, researchers concluded that doctors were less likely to perform aggressive medical procedures or administer certain types of medications routinely prescribed under common treatment guidelines when it comes to black patients. It also found that black patients were almost 25% less likely to receive an antiplatelet medication that wasn’t aspirin, and they were 9% less likely to get medication to reduce blood lipid levels. Perhaps even more alarming, on several levels, is that black patients had an almost 30% lower chance of getting an angiogram and were 45% less likely to undergo therapies such as bypass surgery or angioplasty.

This racial bias — and its negative impact on treatment outcomes and community health — are not limited to black patients. There are also disparities in healthcare between whites and Hispanics/Latinos, Native Americans, Asians and darker-skinned people in general.

It can be readily seen in provider-patient interactions, treatment decisions, transplant decisions, pain management protocols and treatment adherence as well as in disease incidence and prevalence, life expectancy and mortality. According to the National Center for Health Statistics, the mortality rates for blacks are about 20% higher than those of whites and this disparity has not changed since 1950.2

The gap is so pronounced that some diseases, such as prostate cancer, have a higher mortality rate among black men than their white counterparts. And black women, who are less likely to develop breast cancer than white women, are 40% more likely to die from this disease. Another study suggested that black men and women with early-stage breast or lung cancer were less likely to complete treatment than white patients. This statistic held true even when factoring in such variables as age, comorbid illnesses, income and health insurance status.

Explicit versus implicit racial bias

Explicit racial bias is as unacceptable in healthcare as it is in the rest of society. If this is the case, what underlies the ongoing bias toward non-whites? The answer is what is known as implicit racial bias. This is a bias that is often unconscious, unrecognized and that can be triggered by external situations and events.

There is evidence that this type of bias is present among many healthcare providers independent of their specialty area, education and years of experience. Given that close to 75% of physicians are white (and 72% are male), there is more than ample opportunity for this type of bias to affect all aspects of non-white patient care.

The difference in behavior exhibited toward blacks, Latinos and other non-white individuals by healthcare providers with implicit racial bias is often very subtle, although the patient can often detect — and react to — these bias cues. Some of the more common indications of implicit racial bias are:

• Viewing non-white patients as being less cooperative, less compliant, less responsible
• Seeing patients as being high-risk without any historical or empirical data to support this belief
• Keeping black and other non-white patients waiting longer for treatment
• Spending less time with patients of color versus white patients
• Approaching non-white patients with a dominant and condescending tone
• Failing to provide interpreters when needed
• Discounting what patients report about their pain or symptoms because of their color
• Recommending different treatment options for patients based on assumptions about their ability to comply

What is interesting is that many healthcare providers do not exhibit any type of racial bias in their routine, day-to-day interactions with patients but rather their biases seem to be “triggered” when they are busy, distracted, tired or under pressure. Unfortunately, many healthcare providers increasingly find themselves in these types of situations. In some settings, such as trauma care, it is the norm. This can lead to a healthcare provider assuming that a black patient reporting pain is drug-seeking rather than pain-relief-seeking or that a non-white adolescent will not follow through with safe sex guidelines and therefore should not be given counseling or sexually transmitted infection prophylaxis.

Various studies suggest that healthcare providers are not intentionally treating people differently based on skin color or ethnic background but that they, like almost everyone else, have unconscious stereotypes of people who are different than themselves. When put in specific situations, these stereotypes influence their behavior.

Steps to reduce racial bias

Most experts agree that trying to eliminate all bias would be nearly impossible given the unconscious nature of implicit bias. Furthermore, it appears that traditional, cultural or racial sensitivity training does very little to reduce racial bias, either explicit or implicit. Indeed, some suggest these types of training may create resentment on the part of the participants.

If this is the case, can providers realistically take steps to reduce racial bias with the aim of improving healthcare and treatment outcomes for their non-white patients?

It appears that providers can adopt approaches and techniques to achieve positive outcomes in addressing implicit racial bias. Some of these include the following:

• Include potential implicit bias factors as part of providers’ morbidity and mortality conferences to better identify when, how and what could have prevented the bias and its influence on treatment decisions.
• Make the effort and train staff to always practice evidence-based medicine and how to better recognize when their unconscious bias and stereotypes may be a factor in treatment or diagnostic decisions.
• Take time to see patients as individuals rather than as members of a specific ethnic or other group prone to generalizations and try to understand their point of view, life experience and day-to-day stresses.
• Make the effort to create opportunities to meet, talk with and know individuals of other racial and ethnic backgrounds to make it easier to see patients as individuals rather than as racial or ethnic labels.
• Learn to recognize when body language during provider-patient interactions may be giving subtle cues of bias. These include increasing interpersonal distance, not maintaining eye contact and having a closed posture, such as crossing arms or keeping hands in pockets. All these body language signals can impact patient understanding of diagnosis, treatment options and compliance levels.
• Identify and correct individual provider and staff misconceptions that contribute to racial bias. These include false beliefs3 such as those identified in one study among medical students and residents about biological differences between white and black patients (for example, black skin is “tougher” than white skin).4
• Aggregate patient treatment and treatment outcome data to better identify possible racial disparities and ways to reduce them, including more standardized treatment protocols.

The elimination of explicit racial bias in most settings may cause providers to become complacent. It is essential to recognize the existence of implicit bias and avoid taking a “not at my practice” approach to dealing with this important issue.

Admitting that racial bias exists in many healthcare settings is neither easy nor comfortable. But doing so on an ongoing, objective basis is critical to the health and well-being of patients. Their lives literally depend on it. 

Notes:

1. Arora S., et al. “Fifteen-year trends in management and outcomes of non–ST-segment–elevation myocardial infarction among black and white patients: The ARIC Community Surveillance Study, 2000–2014.” Journal of the American Heart Association, Sept. 20, 2018. Available from: bit.ly/2PRlBcd.
2. National Center for Health Statistics. “Life expectancy.” Centers for Disease Control and Prevention. Accessed Oct. 31, 2018. Available from: bit.ly/2mYq8xA.
3. Proactive Health. “Does your doctor have a racial bias? Study suggests false beliefs could affect black patient treatment recommendations.” April 18, 2016. Available from: bit.ly/2OhOixN.
4. Hoffman K., et al. “Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.” Proceedings of the National Academy of Sciences of the United States of America, April 4, 2016. Available from: bit.ly/2SwzuyV.